10 January 2010

We do not want to see the state withdraw from [the NHS] in any shape or form at all.

Yes. That is what he said on The Andrew Marr Show. Does this mean what it seems to mean or was this some very clever use of words? Is it a genuine reassurance or is it false? You could look at the draft manifesto to check but electoral manifestos are written to court popularity and, according to Wikipedia, "the status of electoral manifestos has diminished somewhat due to a significant tendency for winning parties to, following the election, either ignore, indefinitely delay, or even outright reject manifesto policies which were popular with the public". So where should we look for the truth? Perhaps a policy document not so widely read as a manifesto would be the place. And that is what Dr Grumble has done. This is what the Conservatives say in their Renewal/Plan for a Better NHS (pdf):

Over the past eleven years Labour have missed a golden opportunity to work in partnership with the private sector to provide better care, not privately, but free at the point of need on the NHS. Despite believing that market mechanisms work, they have failed to open up the market for the provision of NHS care so as to drive up standards.

We need a level playing field. All NHS patients should be free to choose any provider of care for their treatment – so long as that provider can provide treatment at the NHS price. So that could be an independent hospital or an NHS Foundation Trust, depending on the patient’s preference. Moving to this system, driven by patient choice, means people will get treatment more quickly and there will be a far stronger incentive for standards of care to improve.

Dr Grumble's patients cannot choose a private provider for their care. Not without paying anyway. Actually, and this is the truth, Dr Grumble would not necessarily advise them to obtain private care even if they wished to pay for it. Private care is not necessarily better and Dr Grumble is quite certain that it can be worse. Some of the very best doctors work for the NHS. Getting to the top in the NHS is not easy but any doctor is free to set up privately. It has been like that since 1948. It is one of the great strengths of our health service.

So Dr Grumble is left confused. Apparently David Cameron does not want the state to withdraw "in any shape or form" but we know from the policy documents that NHS patients should be able to "choose any provider of care" which could be "an independent hospital or NHS Foundation Trust". That presumably means a choice of either NHS or private provision or maybe third sector provision. How can that be achieved without "the state withdrawing from the NHS in any shape or form"? You work it out.

OK. If you have read this far you will now be wanting to know exactly what the wording is in the draft election manifesto. Here it is:

To give patients even more choice, we will open up the NHS to include new independent and voluntary sector providers – if they can deliver a service that patients want, to a high standard and within the NHS tariff, then they should be allowed to do so.

So there you have it. Essentially the same thing twice. No real obfuscation - except from David Cameron himself. There will be more independent and voluntary sector providers - full stop. The plans of the major parties for the NHS seem to to be much the same. When David Cameron says "We cannot afford to carry on like this" he is right. He can't. He needs to find something different. Not more of the same.

Posted by
Dr Grumble

51 comments:

Anonymous
said...

The politicians should stop modelling the NHS on the US system and look to Europe instead.

A continental healthcare system would be preferable to both the US system and the current NHS system.

It's strange that anybody should look to the US for the way forward. Theirs is a system that has clearly failed to provide cost-effective health care for all - or even for anybody.

My own feeling is that New Labour should have put the increased funding in more slowly and kept the old system which was highly efficient (in the past) but failed at that time to deliver because of gross underfunding. Unfortunately they put the increased funding in far too quickly and wasted enormous sums on pet projects including new computer systems despite the NHS having a very bad track record with IT. (This is an example of how private providers rip off governments.)

The other mistake that was made was introducing the market. If the NHS cannot even commission a computer system despite putting in billions how can it effectively commission the enormous variety of complex medical care that is needed? Markets cost a lot to run. You need lots of bright people to commission services and move the money about. It's so expensive that you cannot recover the costs from increased efficiency. It might have been reasonable to try this if modestly increased funding had failed to bring about the necessary improvements but Big Business wanted its share of the NHS budget and outside advisors could not conceive of running a system without a market. Yet the NHS did once run that way and was both the envy of the world and the most cost-effective system for a while.

Of course we are stuck with what we have and there is no way Tories or Labour are going to change. David Nicholson once told me that the only purpose to the outside providers was to shake the NHS up a bit. I see no evidence that they are more efficient and quite a lot that they are less efficient. And I fear the Tories have other ideas.

Frankly, I don't think there's much of a choice between the parties in terms of healthcare policy. New Labour have spent money on the NHS but not in the right way; choose and book, for example is farcical. No one likes it, except the government. Then there's the IT link-up that's never going to happen.

Where I work, they've spent millions redeveloping the front entrance. Aesthetically very nice, but surely the money would have been better spent on patient care?

Offices are no longer cleaned by Housekeeping because they are focusing on wards. The admin and clerical staff are responsible for their own rubbish, cleaning and hoovering. This is because money needs to be saved. Surely I'm not the only one to see this as a false economy?!

The front entrance thing is interesting, Hayley. It's no coincidence that yours is a Foundation Trust and clearly feels the need to behave like a private organisation. Private organisations spend a lot on cosmetics - especially front doors. It has absolutely no effect on the quality of care but it creates impressions and a nice entrance, a thick pile carpet and smartly dressed dolly birds are relatively cheap. The last thing these new hospital managers want is the WRVS or what they perceive as old crones from the Friends of the hospital at the entrance. All rather sad in my view. The hospital is no longer a place the community supports. It's just another business.

Just as with the post deregulation where the private sector does not have a universal service obligation, so here, private providers will not have a training obligation and will be free to pick profitable services. Wherever the "NHS Price" is estimated too high, they can make disproportionate profits by providing a heavily advertised and slightly more attractive service. Given a sufficient business process or IT system this can be extended to cherry-pick patients.

The private sector makes the profits while the NHS struggles to treat the "expensive" patients while politicians attack it for being inefficient because its cost per patient is higher.

Nice to live in a country where your choice of political party is right, righter, rightest.

Curiously, Julie, closure following tarting up of the premises has also been the Grumble experience. It is such an odd thing for managers to do. My own suspicion is that they see what is about to happen and decide to spend the money in their budgets before it is taken off them. What other explanation could there be?

You are right Anonymous that private competitors will always be able to undercut the NHS for the reasons that you state. Yet the present government was paying them more than the NHS. And, on top of that, they were not taking the worst cases which were left to the NHS. As you say (and it was the point of this post) as an electorate we do not really have any choice. The only question is which party is furthest to the right because just as Blair moved Labour to the right and kept it there Cameron seems to be pulling the Conservatives to the left. If Blair succeeded (in my view against the odds) could Cameron? I rather doubt it.

i support the idea of turning the nhs into a state backed medical insurance provider, able to cover all, and collect premium via taxes

i see no reason that the state should own all or indeed any of the providers of care, indeed centralised state owned corporations like the nhs are frowned on even in china these days, they have learnt from mao and his false tractor and rice production stats which always reming me of the published lies about nhs performance

whatever we do we need radically improved feedback loops which force incremental impovements, and which reward success and force failing units to close, the current nhs feedback loops of essentially i) the political system ii) the complaints system iii) badly planned and implemented half hearted attempts at "choice"

i would use proven feedback loops, power to the patient, providers of care only get cash if patient gives it to them, patients able to walk out and take their business elsewhere when faced with crap service, etc

Interesting post, especially being an ER doctor in the US. I agree that our model of medicine is not the best example, but I believe what's not noted about the expense and certain failures of US medicine is the legalities and frivilous lawsuits that continue.

The testing and research and care provided by us in the medical field is very good in the US and we hope to be a model for other countries again, and soon.

Agreed, StorytellERdoc. In the US there is the very best of clinical care and research but both come at a considerable price and the system encourages investigation and intervention. Our system has tended to do the opposite which has its stengths and weaknesses. My feeling is that in the UK with limited resources and ever increasing costs from more and more expensive treatments we cannot afford to give everybody everthing possible. But everybody wants it to be Christmas and this reality has not struck home yet. It is the elephant in the room.

I was worried that your frivolous lawsuits might take hold here. There has been some element of this with the introduction of no win no fee but it is not the problem you have.

The trouble in Britain is that we always assume that our way of doing things is best, whatever the subject under discussion.Most of the EU have their equivalent of the NHS, and certainly France and Germany have better results with cancer than we do here. My daughter had problems in Sardinia, and they had her into the hospital, onto a ward before she would even have sen the triage nurse in our A&E. (she knows from experience). Other countries have health services, Australia has a mixed state/private system which appears to work and I'm told the state system in Singapore is much to be admired.So instead of suggesting the government wants to follow the US system, I feel that they should be looking at systems world wide and learning from the best, not resisting change.

Quite a lot of suggestions here for improvement but where has been the public discussion on this? And why do the Conservatives just offer more of the same when even casual comments on this blog suggest that there are many other possible ways forward.

While I am very much in favour of seeing if we can learn from other countries, no country has the solution to the underlying problem of our aging population and ever increasing healthcare costs. Controlling demand has to be part of this. Doctors and patients will always favour more funds for the NHS but there is a limit to what the taxpayer is prepared to pay. There is no healthcare system that is not struggling to meet the demand.

It is true that the UK has been lagging behind but the NHS has had fewer doctors and fewer scanners than most equivalent countries and you cannot expect the relatively recent increase in funding to lead overnight to more fully trained doctors and better cancer figures - espedially since much of that increased money was wasted (including on new contracts for doctors).

Who is over paid Anonymous? The juniors do it for freee! ... or near enough! Sad and disgraceful situation!

And about the seniors, you might argue that European doctors are paid less for more quality and productivity ... but, we are not in Europe ... and we have a different system and a different set of values ... and when in Rome ...!

We don't want our doctors to be underpaid ... much better to pay them well, promote ownership in order to reduce waste and improve on performance and productivity, then hold them to account if they fail to do that. Much more financially effecient than paying little and getting little in return, which would be inevitable when you have angry seniors who have no job satisfaction ... you only get what you pay for after all ... except from the juniors of course who do do an outstanding job just for the love of god!

Actually, isn't this is one reason why Lord Darzi included the promotion of clinical leadership in his excellent and comprehensive review? - to give clinicians the responibility for the money being spent so that waste can be reduced while quality is improved ... brilliant idea - and he never said anything about our docs being over paid either - because, compared to other professionals, they are not! ... so let's keep a lid on it ...

I really don't understand this myth about the great health service in Singapore. It's not great; they only spend 3.7% of their GDP on health and about 2/3rds of that is from private insurance. They have half the numbers of doctors that we have per thousand and the insurance system is something to behold as well. Basically, you set aside money for a rainy day. The amount that you pay into your policy is the amount you have to play with if you fall ill. Now that's ok if you keep good health and you can keep paying contributions into your fund. Your fund can also be inherited by a family member when you die, if it isn't used up. But if you fall seriously ill, and your money is used up, that's it. No more money. Because you are ill, you can't go out to earn any more money. It is not a good system at all.

Healthcare is expensive. It is expensive because you are using highly skilled professionals and very expensive equipment, and the only way that everyone can afford it, is to provide a big enough risk pool so that if someone falls seriously ill they can be accomodated. The simplest and best way of doing that is through general taxation as we do in Britain. As for Europe, Germany's health organisations are in serious trouble just now; they lost a significant amount of funding when the government allowed people to 'opt out' of the established not-for-profit health organisations to buy cheaper private insurance instead. The people who opted to do that tended to be in a higher wage bracket (health insurance is proportional to your wage). They are going to lose out when they find out that private insurance will only cover them so far, but the German health system is haemorraghing at the momemt. Angela Merkel tried to prop it up by putting up VAT and using that money to help, but it's all a bit of a mess just now.

"And about the seniors, you might argue that European doctors are paid less for more quality and productivity ... but, we are not in Europe ... and we have a different system and a different set of values ... and when in Rome ...!"

So, we are not part of Europe? How ridiculous! And it is also ridiculous to suggest that doctors in the UK are underpaid compared to other professionals.

It is horrible that david cameron would even consider privatization. The whole model is a downright shambles. Every year in the US thousands die due to lack of health insurance and even more die because their expenses for a procedure such as a liver transplant have been rejected (insurance wont pay for it) because they say it is an "experimental procedure". People are given basic care and if they have no insurance they are out. Something many medical dramas in the US seem to casually neglect.

The most shocking thing is that in the US health insurance reviewers, who review claims for treatment get paid based on the amount of cases the reject. It is truly disgusting.

I agree that with private companies comming into this field that there will be some advantages such as improved technology due to increased capital in some instances such as improved scanners, tests. Higher research budget etc.. But once you bring private individuals in the aim of a private corporation which is "to provide a service and break even" is quickly replaced with "Make a profit" So one could guess that the level of care will go down in some areas.

David cameron needs to think and whoever thought of bring non-medical people in to make overall decisions which affect millions (I am including advisors who are doctors, yet ministers dont seem to listen to them very much eg prof. Nutt) It is absolutely absurd and the whole system needs reformed not just the NHS.

I do agree with Julie that the only way to tackle the problem of healthcare is to have everybody contribute according to their ability to pay. The way we do it from general taxation is a good one.

Everybody should have the things in healthcare that are really important but it has to be recognised that there have to be limits. We should be provided with the healthcare we need if it reasonably cost effective but not everything we might ideally want. No such system can afford that. If the rich want to buy the extras that is OK but they should not opt out of contributing to the general fund for the rest of us.

Many very wealthy people use the NHS - especially general practice. Only today I saw a banker as an NHS patient - though he did tell me his occupation with an element of shame!

So they say, only I feel traditions are still the same as before the union - so, when in Rome .. and when in London .. still apply :-)

"And it is also ridiculous to suggest that doctors in the UK are underpaid compared to other professionals."

Well, judging by my friends alone, the senior docs I know, mostly late forties and upto late fifties age wise, their salary plus any extras are made by 30 year old's in other industries and I know some of those too ... and let's forget about the bankers and their still very much alive bonuses, eh!

Incidently, what do you think of the juniors pay and the extra hours they do for free Anonymous? Is it fair?

"Over the past eleven years Labour have missed a golden opportunity to work in partnership with the private sector".

Surely Cameron actually meant NuLab have already upstaged my lot by leaving no stone unturned in pursuit of doing business with the profiteers?

To date NuLab have committed £2.7 billion to ISTCs

PFI schemes account for a further £63.5 billion

On top of these substantial sums the NHS has to factor in the cost of 'Out-of-Hours' care (often supplied by private providers) as well as the likely dosh required to commission bids for ill considered, and largely unwanted Polyclinics.

And how much have NuLab spent on management consultants for the likes of the NHS supa-computer?

Meanwhile former NuLab health ministers trip over themselves to exploit insider knowledge on the board of companies trying to muscle their way into the lucrative health market.

Exactly, a&e charge nurse. New Labour adopted Tory-style NHS policies (which have wasted and not saved money) and the Tories seem to have no new ideas whatsoever. Their main criticism if you read their policy documents is that New Labour did not go far enough fast enough. That's hardly an alternative to vote for.

When you think of other Labour policies we might have concerns about, say, Iraq it seems that the Tories were more in support of Blair than Labour themselves. In fact when Labour has blundered it seems that the Tories have tended to egg them on and not put them right. There has been scant genuine opposition.

..although you could just as easily substitute the Hugh Grant character in Four Weddings and A Funeral for Bertie Wooster. I can't watch Four Weddings now without the eerie feeling that "Call Me Dave" is going to stroll into shot at any moment.

As to the NHS... in an odd way what we currently have resembles the German system in the sense that by buying "extra" insurance you can get privileged access to some things (speedier non-urgent scans, faster minor ops, possibly expensive new cancer drugs for which the evidence is so-so, etc.). Having seen both systems in action (albeit only as a patient's relative and doctor's spouse) it seem to me that the central difference is that the Germans are prepared to pay more for theirs. Oh - and that "political" micro-interference is far less than in the UK.

Sam said... And about the seniors, you might argue that European doctors are paid less for more quality and productivity ... but, we are not in Europe ... and we have a different

system and a different set of values ... and when in Rome ...!

We don't want our doctors to be underpaid ... much better to pay them well, promote ownership in order to reduce waste and improve on performance and productivity, then hold them to account if they fail to do that.

European GPs still do more home visits and handle their own out-of-hours for less money than their UK colleagues.

UK GPs took a massive pay rise at the same time as ditching their responsibility for our-of-hours.

Paying doctors more certainly does promote ownership... that is to say ownership of profits!

Incidently, what do you think of the juniors pay and the extra hours they do for free Anonymous? Is it fair?

Sam, in many competitive industries you will find graduates working quite literally for free for long periods of time to get the necessary experience they need to get ahead.

Some grads I know work for free and their lifestyles have to be funded by their parents. Others work 16 hours a day, 8 hours in an unpaid internship and 8 hours behind a bar on the minimum wage - they live (with much difficulty) on half the minimum wage.

These graduates who work for free don't benefit from an NHS pension or other perks of working for the public sector.

Certainly, junior doctors may feel aggrieved when they look at the salaries of bankers or footballers. Most people feel that way.

"European GPs still do more home visits and handle their own out-of-hours for less money than their UK colleagues.UK GPs took a massive pay rise at the same time as ditching their responsibility for our-of-hours.

Paying doctors more certainly does promote ownership... that is to say ownership of profits!"

Then ask them to take out of hours back - but don't penalise them because some not very clever person in government agreed a contract with them that was, in the eyes of government afterwards, stupid! It takes two hands to clap after all! IMO, this is the consequence of not having someone 'in the know' in government! I bet had there been a doctor in power then, this contract would have looked very different! So, it is not the GPs you need to blame because they simply negotiated a contract that takes care of their intrests,or as you put it 'profits'- much like any other profession in the public sector does when it negotiates a contract with government. And we all live on our 'profits', don't we?

"Sam, in many competitive industries you will find graduates working quite literally for free for long periods of time to get the necessary experience they need to get ahead.

Some grads I know work for free and their lifestyles have to be funded by their parents."

Sure, we all know 'some' of those graduates. In this current economic climate, those you mention are even the lucky ones, considering only 30% of class 2009 were able to find anything at all! Sad!

But there are two points to consider with young docs, first, they spend double the time at uni .. and you hardly find graduates working for free three years after graduation. Second, of course you know how tough a life it is to prepare a child for medical school, right from birth literally. Not only ensuring they are to grow to be the best of their class all along only but to have extra interests and activities to prove they are not book worms but can manage their time well, multi-task and be coutious and sociable, compassionate .. etc too! Surely those of that same 'pick of the crop' others who graduate other diciplines do not work for free, do they? The ones I know don't anyway, one much less in ability than my children, is making double the money 2 years after graduation - my child was still preparing for their tough finals still! And I do supplement their income you know, honest! specially during the foundation years. It can't be right, eh? :-D

Unless you reward people properly and in corrolation with what they offer you, the notion of demanding excellence and dedication from them becomes a mirage!

There is all this talk now about learning from other industries how to improve safety ... etc, why not also learn how to improve front line staff contentment, as happens in the private sector - then demand and insist on quality from them ... (please read about 'Google's staff, for example) ... and save the money you want to save! - and btw, this is the safest and most proven way to cutting costs and reducing waste - investing in talent :-)

As for bankers and footballers, why didn't anyone tell me! I would've learned to play the stuff mysel and been wealthy enough to spare my children the agony of preparing and studying medicine!

Don't believe that! I HATE football! - grown up men fighting over a rounded piece of skin - indeed! - give them a ball each and let us live in piece! :-D

Trainer 1 thinks Dr Grumble is right. The NHS is being privatised deliberately. It would be a defianace of logic to think otherwise.

NHS privatisation is what we have all come to recognise as an 'agenda'. As a general rule when one is confronted with an 'agenda' one must ask the following.

If the agenda is politically unpopular (at times politically suicidal) what is motivating the politicians to drive it?

Have politicians or policy makers suddenly recanted previous beliefs and become converts to the agenda? If so why?

Does the agenda continue regardless of changes in political (or other) leadership?

Are'charities', think tanks, IGOs and NGOs or other'change agents' (who sit outside democracy) involved. If so who is funding them, and why?

If the agenda flies in the face of evidence, seems to conflict with the stated aim and generally defies common sense, is it possible that there is another aim which has not been stated?

Cicero, in Roman times, applied simple logic and asked "Cui bono?". In these baffling times of mind-boggling bail-outs, inexplicable wars and dubious viral threats to 'all humanity' we must not forsake our logic. Denial and doublethink is no refuge.

Trainer 1 thought the third way was to be a gentle free market and a socialist 'safety net'. Few realised this actually meant widescale corporate capture with a soviet 'big-state' deployed to advance coporate interests.

To see this in action, on a 'global' scale, one only needs to look at this.

"And about the seniors, you might argue that European doctors are paid less for more quality and productivity ... but, we are not in Europe ... and we have a different system and a different set of values ... and when in Rome ...!"

It could of course be argued that doctors in the rest of Europe are paid the market rate because they operate within the private sector; and don't forget that NHS employees pay nothing like the true cost of their pension benefits, something which Cameron has promised to rectify if the Conservatives are elected.

"something which Cameron has promised to 'rectify' if the Conservatives are elected."

Rectify?! You see, this is the problem with modern British politics, this incredible raid on people's livelihoods while at the same time wasting billions on failed initiatives like the swine flu 'panacademic'! How many docs and nurses could you pay with 'half' of this wasted money?! And, why should those on the frontline have a pay freeze when there is all this money around but is being squandered?! I wonder if that money was used to better wages, would it translate into 10+% increase for a strapped for cash junior or graduate nurse? What percentage would you estimate?

That's why people are disillusioned with all parties because they are told one thing and see another! Again, I think any party would be stupid to attempt to 'rectify' public sector pensions when people are in that state of doubt. I suppose it is best for a clever politician to put his own house in order first - 'if' they get elected - and that applies to anyone. And if you choose to refer to the public sector, please compare like for like 'in this country'- how much does a successful Harley Street consultant make per annum on top of their NHS wage?! Who needs a subsidised pension then? Only the current system does not allow for enterpeneurialship but for the very lucky few ... and I can't see that changing soon because that will mean the end of the NHS as we know it.

So, you have to choose, either to subsidise or prepare for and allow enterpenurialship - because people can not survive on water alone.

"and you hardly find graduates working for free three years after graduation".

That's simply not true, Sam - according to this item;"Annual employment figures show NURSES work an average of more than four hours unpaid every week, and more than seven if they do overtime".http://news.bbc.co.uk/1/hi/wales/7411785.stm

So, the NHS benefits from virtually a full days work, gratis from the overtime cohort of nurses - I'm sure the same goodwill would not exist if your boss was a sinister beardy like Richard (don't pay the cabin crews) Branson.

Do the maths - there are 400,000 nurses in the NHS, most are expected to work additional, unpaid hours irrespective of their grade (year in year out).

The marketeers never seem factor the cash benefits (for patients) associated with staff commitment to the NHS ethos.

It goes without saying that the gargantuan volume of work carried out for free by yesteryears junior doctors kept the NHS rumbling along - now some of this work has been devolved to the quacks, and while the quacks might be loathed (by some) at least they put in their fair share of unpaid work as well.

Sam, I didn't realise your children were medics, that explains your personal motivation for believing that they have it worse than everyone else and that they should be paid large sums etc.

I know graduates who are far more educated than the average doctor (ie. with Phds), who are working for free. The more competitive the industry you enter, the more likely you are to spend a stint working for free.

You seem to operate under the illusion that medicine is the most competitive of careers. Perhaps at the point of university entry (ie. Alevels) it is.

However there are many post-university careers that operate more extreme competitive entry procedures. I have medic friends who have tried - and failed to enter such fields.

So, it is not the GPs you need to blame because they simply negotiated a contract that takes care of their intrests,or as you put it 'profits'- much like any other profession in the public sector does when it negotiates a contract with government.

Sam, I think that in a system where resources are limited, GP partners should take some responsibility for curbing the amount they profit from the system. It's all very well for doctors to complain about an under-resourced system but surely it is worth analysing where the money is being spent?

I'd be happy to pay higher levels of national insurance for a continental-style healthcare system. But I'd like to think my tax money was going on treatments, equipment, provision of more nurses etc. than on paying for some GP partner's third BMW.

If other European nations can provide greater amounts of higher quality healthcare, delivered by more doctors at cheaper wage levels, then why can't the UK?

Some people are motivated to work hard because they take pride in their work. Others are motivated to work hard because they feel committed to a particular cause. Not everybody's modus operandi in life is to own the biggest house or the fastest car.

Perhaps, European medical schools attract applicants who are less money-driven and more socially responsible.

"that explains your personal motivation for believing that they have it worse than everyone else and that they should be paid large sums etc."

When did I ever speak of large sums?! ... and I NEVER speak about my children alone but about young medics in general! People should be paid their worth, in whatever field! A graduate medic deserves more than the current pathetic £21k, Surely!

"I know graduates who are far more educated than the average doctor (ie. with Phds), who are working for free. The more competitive the industry you enter, the more likely you are to spend a stint working for free."

I am aware of that but it depends what PhD you have and if it is worth the paper it is written on because with 'real' PhDs you normally have no problem. That said, two wrongs don't make a right, so, those need to fight for their rights too.

And by the time the medics graduate, they would have already worked for three whole years for free too; uni being three years longer. And they do give the extra free hours, lots, once they graduate and start work too. Because a medic can not exactly say' it's 5pm, I'm off' when they are in theatre for example, can they? Actually, I know one young doctor whose hospital insists on NOT working more than the 48 hours now imposed by the EWTD, ie, 9 to 5pm and that's it, no more allowed. But then the ward rounds are at 7- 7.30am and theatre is on till 6pm, then you need to check on patients ... so in effect, they work 12 hours minimum a day without any overtime allowence! ... and the hospital just says, you can go home if you wish ... but, can they? Generous, don't you think? At least give them a decent minimum pay to be able to live with dignity!

I also know a couple of medics, both f1s who can't get married because they won't be able to support a home financially so, they won't .. yet!

"You seem to operate under the illusion that medicine is the most competitive of careers. Perhaps at the point of university entry (ie. Alevels) it is."

No, I don't. Medicine is a calling and that's how people get into it - because of the job itself.

"However there are many post-university careers that operate more extreme competitive entry procedures. I have medic friends who have tried - and failed to enter such fields."

Luck of the draw! So, one would get in and one would not despite both being of equal calibre. And since the field your friend was trying to get into is extreme re competition, it doesn't mean he was below standard though, right? ... Because it's always like that in those cases since employers/unis have to stick to certain quotas ... medical schools are famed for this nowadays as it seems they are turning the taps down a bit post MTAS

"Sam, I think that in a system where resources are limited, GP partners should take some responsibility for curbing the amount they profit from the system. It's all very well for doctors to complain about an under-resourced system but surely it is worth analysing where the money is being spent?

I'd be happy to pay higher levels of national insurance for a continental-style healthcare system. But I'd like to think my tax money was going on treatments, equipment, provision of more nurses etc. than on paying for some GP partner's third BMW.

If other European nations can provide greater amounts of higher quality healthcare, delivered by more doctors at cheaper wage levels, then why can't the UK?"

You are under the impression that I am differing with you when I am not. It is my modus operandi too (I love this expression! :-) that when I contract someone to do something for me, that I 'try my best' to get value for my hard earned money too - so we are in agreement about that. The 'only' difference we have is that I don't believe that making money is a sin! Or indeed, that poverty is a sin either! If those GPs provide quality work that is also good value for money, I don't care how many BMWs they have parked in front of their manor house. Different if they don't, so, we're in agreement!

However, what I also was trying to say is that once 'you' contract someone, say, to change at tap in your house, you can't come back and ask them to drop the price simply because you now find you could have had it done cheaper else where!

If 'some' GPs are 'milking the system' then you need to exert control 'on the system' so that you can get your value for money.

So, see, we're in agreement but I think private sector, you think public sector ... I am sure the best way is to adapt the best methodology from both; ie, I will pay well but I want my money's worth! ... so, those who don't, go after them, ask for your money's worth ... or else!

"I'd be happy to pay higher levels of national insurance for a continental-style healthcare system. But I'd like to think my tax money was going on treatments, equipment, provision of more nurses etc. than on paying for some GP partner's third BMW."

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This is precisely why Cameron needs to consider radical reform. Under NuLabour most of the extra spending on the NHS was spent on pay rises!;)

"This is precisely why Cameron needs to consider radical reform. Under NuLabour most of the extra spending on the NHS was spent on pay rises!"

Wot! More reform! And any reform will never be as compresensive, accurate and thourough as Darzi's - because he took to the road for a whole year and listened before he decided - and he is a top doctor, top academic too! It works best if the reform is done by the best! The conservatives can not match that if they stood on their heads!

That's why Cameron must never be allowed into that office!

Watch that video where a wise nurse was just talking about this non ending reform, she said (Second half of video) that staff needs 'a period of consolidation' - How right she was too!

To get back to the original comment, Britain has much to learn from our European neighbours who seem to run much more efficient health sevices than the poor old NHS. This hasn't been ignored by centre-right pressure groups who advocate a state-backed social insurance model. I cannot understand why so many doctors are opposed to such a system whoch would give them more professional independence than a micromanaged state-run nationalised monolith.

You may be right, David, that there would be some personal advantages to doctors to have an insurance system. But many of us do not believe that such a system can possibly be efficient.

We are told that systems like the French one are very much better than ours but the French system is struggling and you cannot compare the quality of care in France with that in the UK given that until recently the NHS was grossly underfunded.

In 2003 the UK had 2.2 doctors per 1000 people whereas France had 3.37 (2004 figures). So in France you have 3 doctors doing work which in the UK would be done by just 2 doctors. It says very little about the systems and more about the funding at the time.

Insurance systems waste money moving the money about. Unfortunately that is now happening in the NHS and accounts for the increase in managers who are needed to commission services and sort out the billing. That, many of us would contend, is never going to be an efficient way of doing things though we are now stuck with it since the policies of the main parties do not differ on this.